Eligible Employee Instructions: Please mark all boxes and ...

SI 7533D-643146 (12/16) 1 of 2 (08/03) For questions Please visit the CalHR website: State of California, Group No. 643146 Long Term Disability Enrollment and Change Form Eligible Employee Instructions: Please mark all boxes and complete sections A, B, and C. Fill out online or use a ball-point pen and print clearly. Send completed form to your Agency Personnel/Payroll Office. Please keep a copy for your records. Section A Applicant 1. Type of Enrollment New Enrolling for the first time Canceling Plan Changing Plan Option 2. Your Soc. Sec. No. 3. Your Name (First, Middle, Last) 4. Date of Birth 5. Your Address 6. City 7. State 8. ZIP9. Job Title/Occupation 10. Gender Male Female Section B LTD Plan Options 1. Please select your LTD Plan option below. Then complete item 2. OPTION A 65% MISCELLANEOUS/NON-SAFETY/OASDI EMPLOYEES (075-111) Under Age 30 30-39 40-49 50-59 Over 60.

OPTION B – 55% BENEFIT OPTION Under Age 30 30-39 40-49 50-59 Over 60 .00014 .00043 .00102 .00206 .00229 . 2. Please calculate your monthly premium by …

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